Can Laparoscopic Pancreaticoduodenectomy Be Safely Implemented?

Introduction  

The implementation of laparoscopic pancreaticoduodenectomy (LPD) has been appropriately met with apprehension, and concerns exist regarding outcomes early in a program’s experience. We reviewed our early experience and outcomes of LPD.     

Can Postoperative Nausea and Vomiting Be Predicted?

Background: Retrospective [1] studies fail to identify predictors of postoperative nausea and vomiting (PONV). The authors prospectively studied 17,638 consecutive outpatients who had surgery to identify these predictors.

Methods: Data on medical conditions, anesthesia, surgery, and PONV were collected in the post-anesthesia care unit, in the ambulatory surgical unit, and in telephone interviews conducted 24 h after surgery. Multiple logistic regression with backward stepwise elimination was used to develop a predictive model. An independent set of patients was used to validate the model.

Results: Age (younger or older), sex (female or male), smoking status (nonsmokers or smokers), previous PONV, type of anesthesia (general or other), duration of anesthesia (longer or shorter), and type of surgery (plastic, orthopedic shoulder, or other) were independent predictors of PONV. A 10-yr increase in age decreased the likelihood of PONV by 13%. The risk for men was on third that for women. A 30-min increase in the duration of anesthesia increased the likelihood of PONV by 59%. General anesthesia increased the likelihood of PONV 11 times compared with other types of anesthesia. Patients with plastic and orthopedic shoulder surgery had a sixfold increase in the risk for PONV. The model predicted PONV accurately and yielded an area under the receiver operating characteristic curve of 0.785 +/- 0.011 using an independent validation set.     

How Can Prognosis for Diabetic ESRD Be Improved?

Although the prognosis of patients who have diabetes and are receiving renal replacement therapy has greatly improved, survival and medical rehabilitation rates continue to be significantly worse than those of nondiabetic patients, mainly because of pre‐existing severely compromised cardiovascular conditions. In this scenario, the nephrology community had to do its best in order to offer the best treatment options to these patients using a multifaceted approach. The most common RRT modality in patients with diabetes is still hemodialysis, but it gives rise to a number of clinical problems, in particular difficulties in the management of the vascular access and high frequency of intradialytic hypotension. Recent data suggest that efficient high‐flux treatments have the potential of improving morbidity and mortality of diabetics with ESRD. Sodium profiling during the dialysis session may be also of importance in reducing intradialytic hypotension and helping in achieving the prescribed body weight. Patients who have diabetes and are on peritoneal dialysis have to face a progressive increase in peritoneal permeability, loss of ultrafiltration, and peritoneal fibrosis, all phenomena being accelerated in patients with diabetes and ultimately leading to an increased technique failure. However, the two dialytic modalities are comparable in terms of outcomes in the short term.     

How Many Contralateral Papillary Thyroid Carcinomas Can Be Missed?

Background

When surgeons decide to perform lobectomy as the treatment of papillary thyroid carcinomas (PTCs), they must consider the possibility of contralateral cancer. We wanted to determine the incidence of bilateral PTCs (bPTCs) and analyze their characteristics. We also wanted to determine how many patients with bPTC were missed preoperatively.

Methods

From January 2007 to May 2011, a total of 466 patients with PTC who were treated by total thyroidectomy at a single institution were enrolled. Patients were divided into two groups based on bilaterality. The patients with bPTCs were further investigated regarding the preoperative presence of the contralateral tumor.

Results

Bilaterality was seen in 29.8 % of PTC patients. In all, 36.8 % of PTCs ≥1 cm, and 25.7 % were papillary thyroid microcarcinomas (PTMCs). The presence of PTC in the contralateral lobe was missed in 15.8 % of bPTCs and in 21.3 % of bPTMCs. The rates of preoperatively nondetected contralateral cancer were 4.7 and 5.5 % for PTCs and PTMCs, respectively. Tumor size and multifocality were factors associated with bilaterality (p = 0.014 and p < 0.001, respectively).

Conclusions

Bilaterality is found more frequently when the tumor is large. Multifocality also can help predict the possibility of bilaterality. Therefore, total thyroidectomy may be necessary for patients with a multifocal or large tumor. It should be noted that the presence of a contralateral cancer is missed in 4.7 and 5.5 % of patients with preoperatively diagnosed unilateral PTC and PTMC, respectively.